Refresh Your Consult Coding Skills and See Why These Codes Earned a Star

Thu, Mar 30, 2017


coding for consultation

Consultations didn’t go the way of the dodo when Medicare decided to stop reimbursing the codes specific to those services. Some private payers still reimburse office and outpatient consult codes 99241-99245 and inpatient consult codes 99251-99255, as long as you follow the rules.

Recharge your consult coding batteries with these documentation reminders along with a special update for 2017.

Check Off Every R for the Medical Record

When talking about coding consultations, you’ll generally see reference to three Rs: request, render, and report. Many times you’ll also see a fourth R, reason, worked in with the request requirement. Let’s flesh that out a bit more.

Request: CPT® guidelines state that there must be documentation of a request by a physician or other appropriate source for the consultation in the patient’s medical record.

Reason: Including the reason for the request helps support the medical necessity for the encounter.

Render: You’ve got to supply the consult before you ask the payer to reimburse you for it, of course.

Report: The consulting provider must have her own record of the visit but also must share her opinion and information in a written report to the requestor on any services ordered or performed.

What Rs Do You Want to Avoid?

Responsibility for managing the patient’s condition is one R you have to watch out for. If the consultant takes on responsibility for managing the patient’s condition (all or part) before completing the consultation, then you shouldn’t use a consult code. Use another appropriate E/M code instead.

Another R to beware of is referral. Documenting the term referral or referring physician may lead to the interpretation that transfer of care, not a consult, was the intended plan all along.

Shine a Light on What’s New This Year

In a nod to these changing times, 99241-99245 and 99251-99255 sport stars in the 2017 CPT® manual, identifying them as codes that may apply to synchronous, real-time telemedicine services.

When reporting these services as telemedicine consults, be sure to follow your payer’s rules on which place of service to use (such as 02 for telehealth) and which modifier to append (such as GT, Via interactive audio and video telecommunication systems, or 95, Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system).

What About You?

Do you still use consult codes? Have you coded for any telemedicine E/M services?

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Here’s What’s New in Q2 for CCI, MPFS, and HCPCS

Mon, Mar 27, 2017



It’s almost April! In addition to a potential end to the yellow pine pollen covering every surface outside my home (yours, too?), April means second quarter updates to Correct Coding Initiative (CCI) edits, fee schedules, and HCPCS. Ready for some highlights? Let’s go!

CCI for Moderate Sedation Goes Retro

If you read this blog regularly, you know that the big CCI news for moderate sedation is the retroactive deletion of several erroneously added edits. The list of deletions is almost identical to the original announcement, but there is one difference.

The CCI contractor originally stated it was an error to have edits bundling moderate sedation codes 99151-+99153 into 45990 (Anorectal exam, surgical, requiring anesthesia (general, spinal, or epidural), diagnostic). But the April 2017 version of CCI keeps in place the moderate sedation edits for 45990, which you may have noticed refers to general, spinal, or epidural anesthesia.

Remember: Retroactive deletion back to the date of the creation of the edits means it’s as if the edits never existed. If you received denials for moderate sedation based on those specific edits, you may appeal the denial (or follow your payer’s preferred process) to get those denied codes paid after the April 1 update is implemented.

38,000 to go: There are more than 38,000 changes in the quarterly update for physician/practitioner CCI edits (and for the outpatient CCI version, too), including many affecting lab and nerve block codes, so be sure your CCI resource is up to date and that you check for edits before you submit your claims.

MPFS Goes Back in Time, Too

Retroactive changes aren’t limited just to CCI. The Medicare Physician Fee Schedule (MPFS) will have some changes implemented April 3 but effective back on Jan. 1, 2017. MLN Matters MM9977 offers a list of changes. Here’s a quick look:

  • Presumptive drug test codes G0477-G0479 change to procedure status I, meaning the codes aren’t valid for Medicare (adding to a grab-bag of changes related to these codes for 2017)
  • Spine stabilization codes 22867 and 22869 change the assistant surgery indicator from 1 (no payment) to 2 (payment allowed)
  • Ophthalmic biometry codes (professional component) 76519-26 and 92136-26 get bilateral surgery indicator 3
  • Physical therapy eval codes 97161-97163 see a PE RVU increase from 0.98 to 1.00
  • Occupational therapy eval codes 97165-97167 see a PE RVU increase from 0.91 to 1.32
  • Occupational therapy re-evaluation code 97168 sees a PE RVU increase from 0.65 to 0.93.

Tip: MPFS isn’t the only Medicare fee schedule that gets an April update. Confirm that you have current information for areas like DMEPOS, ASC, and drugs, too, if they affect you.

HCPCS Gains Some C Codes

Finally, for you outpatient coders, there are some new OPPS pass-through drug HCPCS codes effective April 1:

  • C9484 (Injection, eteplirsen, 10 mg)
  • C9485 (Injection, olaratumab, 10 mg)
  • C9486 (Injection, granisetron extended release, 0.1 mg)
  • C9487 (Ustekinumab, for intravenous injection, 1 mg)
  • C9488 (Injection, conivaptan hydrochloride, 1 mg).

How About You?

Which quarterly updates affect you? Did you hold your moderate sedation claims until the CCI change?

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How Do AHCA Amendments Affect Medicaid?

Thu, Mar 23, 2017


US capitol building

The US House of Representatives is scheduled to vote on the American Health Care Act (AHCA) today, Thursday, March 23, 2017. To put it mildly, there are more than a few opinions out there about AHCA. The GOP bill repeals and replaces the Affordable Care Act, often called the ACA or Obamacare. If the bill passes in the House, it will move on to the Senate for consideration. [UPDATE: The AHCA was pulled before a vote was taken in the House.]

Repealing the ACA was one of the issues President Trump campaigned on. Another bullet point in his campaign’s healthcare position statement was a switch to block grants (lump sums) to states to reduce federal involvement in and oversight of Medicaid. Block grants came up in the amendments to the AHCA from House Republicans on Monday. Here’s a quick overview of some of these last minute amendments related to Medicaid.

End Expansion

The original bill included phasing out Medicaid expansion for certain childless, able-bodied adults, and an amendment accelerates the process. The ACA included an enhanced Federal Medical Assistance Percentage (FMAP) for Medicaid expansion. In short, the FMAP is the percentage rate of expenses that the federal government pays states. Among other changes, there is an AHCA amendment that limits the enhanced FMAP to states that expanded Medicaid coverage to the specified able-bodied adults as of March 1, 2017 (a date that has already passed).

Allow Work Requirements

Also in the amendments is a 5 percent increase in federal assistance for a state that institutes a work requirement for able-bodied adult Medicaid recipients. Able-bodied essentially means not disabled, not elderly, and not pregnant. The amendment allows for a variety of definitions of “work” and for exceptions to the requirement.

Family work status statistics available for 2015 indicate that 63 percent of nonelderly Medicaid recipients have at least one full time worker and another 14 percent have a part time worker, for a total of 77 percent.

Offer Block Grants

At the present time, Medicaid funding involves the federal government paying states for a certain percentage of program expenses, as mentioned above in the FMAP discussion. The percentage varies by states.

The current bill includes a per capita cap system, which means the state gets a set amount per person enrolled.

An amendment offers a block grant option (not applicable to elderly and disabled participants), which would give the state a fixed amount not tied to the number of participants. That approach means the amount to the state wouldn’t adjust for increases in enrollment. The block grant approach gives states a lot of leeway in deciding who gets covered and what services are available to them.

Members of individual provider types, like facility or home care, raise the question of who will win and who will lose state by state as different groups vie for resources.

How About You?

How do you see a change from the ACA affecting your job?

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Work Your Way Through This Vertebroplasty Coding Example

Thu, Mar 16, 2017


coding for vertebroplasty

When you think of all the bits and pieces a spine includes, it’s no surprise coding for spine services can get complicated. Today we’ll tackle this tough subject by walking through an example from Orthopedic Coding Alert.

Here’s the example: The operative note shows bilateral vertebroplasty at vertebrae T10, T11, T12, L1, and L2.

Which CPT® codes should you report?

Narrow Your Options to Vertebroplasty Codes

CPT® includes vertebroplasty and vertebral augmentation (like kyphoplasty) in the sequence 22510-+22515.

Codes 22510-+22512 are specific to percutaneous vertebroplasty:

  • 22510-+22512, Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance

Codes 22513-+22515 apply to percutaneous vertebral augmentation:

  • 22513-+22515, Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g., kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance

Our example says the case involves vertebroplasty, limiting us to 22510-+22512, but determining which spine stabilizing procedure is involved in a real case may be more difficult. Keep these pointers in mind:

  • Vertebroplasty: The provider injects bone cement into the fractured vertebra.
  • Vertebral augmentation: The provider injects bone cement into the fractured vertebra after augmenting the vertebral height, which typically involves using a balloon catheter to create a cavity for the bone cement, often polymethylmethacrylate (PMMA). Terms like balloon, inflatable bone tamp, balloon-assisted percutaneous vertebroplasty, and kyphoplasty may point you to 22513-+22515.

Add Your Code Options

Now that you’ve narrowed your code options to 22510-+22512 for vertebroplasty, the time has arrived to choose the codes — and units — specific to the case.

Report one unit of 22510 (… cervicothoracic) for the primary thoracic level T10.

For the two additional thoracic levels (T11 and T12) and the two lumbar levels (L1 and L2), you should report a total of four units of add-on code +22512 (… each additional cervicothoracic or lumbosacral vertebral body [List separately in addition to code for primary procedure]).

Be sure to catch that you reported a single primary code even though the service involved both the thoracic and lumbar spinal regions.

Note that this coding also follows two important rules established by the code descriptors:

  • Each code unit represents one vertebral body
  • Each code is appropriate regardless of whether the service is unilateral or bilateral, so you should not append modifier 50 (Bilateral procedure) or report double the units for a bilateral service.

How About You?

What terms help you determine which of these codes to report?

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Don’t Pack Away Those Flu Coding Skills Just Yet

Fri, Mar 10, 2017


flu diagnosis coding

It’s March, so stuffy noses may make you think more of allergies than the flu, but flu activity remains elevated in the U.S. And the MLN Connects from March 9 says “it is not too late to get vaccinated.”

We’ve gone over coding for flu vaccinations in 2017. Now let’s take a look at ICD-10-CM rules to code for those patients who get the flu.

The codes we’ll be talking about are in these categories:

  • J09.-, Influenza due to certain identified influenza viruses
    • Use this category for novel influenza A, like H5N1, avian, and swine flu.
  • J10.-, Influenza due to other identified influenza virus
  • J11.-, Influenza due to unidentified influenza virus.

Rule 1: Don’t Demand Lab Test to Consider Case Confirmed

You need a confirmed case of a specific type of flu before you report a code from J09.- or J10.-, according to Section I.C.10.c of the 2017 ICD-10-CM Official Guidelines for Coding and Reporting.

Expert tip: “In this context, ‘confirmation’ does not require documentation of positive laboratory testing specific for avian or other novel influenza A or other identified influenza virus. However, coding should be based on the provider’s diagnostic statement that the patient has avian influenza, or other novel influenza A, for category J09, or has another particular identified strain of influenza, such as H1N1 or H3N2, but not identified as novel or variant, for category J10,” the Official Guidelines state.

Rule 2: Steer Clear of J09.- and J10.- When ‘Suspected’ Appears

You may not need a lab test to confirm what kind of flu the patient has, but don’t take that leeway too far.

The Official Guidelines state, “If the provider records ‘suspected’ or ‘possible’ or ‘probable’ avian influenza, or novel influenza, or other identified influenza, then the appropriate influenza code from category J11, Influenza due to unidentified influenza virus, should be assigned.”

In other words: Don’t use a code from J09.- or J10.- when the documentation shows the provider isn’t certain about the type of flu the patient has.

Rule 3: Turn to J11.1 for NOS Cases

When all you know is that the patient has influenza, you should report J11.1 (Influenza due to unidentified influenza virus with other respiratory manifestations).

Notes with J11.1  in the ICD-10-CM code set tell you the code applies to all of these diagnoses:

  • Influenza NOS
  • Influenzal laryngitis NOS
  • Influenzal pharyngitis NOS
  • Influenza with upper respiratory symptoms NOS.

How About You?

Are you still seeing flu cases? Do you brush up on seasonal coding before the rush hits each year?

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Women’s Health in Focus – ICD-10-CM Codes for Encounters and Conditions Commonly Reported for Female Patients

Wed, Mar 8, 2017


What better time than International Women’s Day (March 8) to focus on women’s health? We’ve pulled together 15 common conditions and encounter-types in an ICD-10-CM infographic.

Women’s Health in Focus

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Get a Glimpse at Potential 2018 MACRA Coding Requirement for Patient Relationship Category

Fri, Mar 3, 2017


MACRA provider patient relationship categories

There could be new HCPCS modifiers coming your way as part of MACRA to identify patient relationship categories. If the term “patient relationship categories” is new to you, then here’s a brief overview.

MACRA requires patient relationship categories and codes as part of an effort to improve resource attribution to clinicians. So there’s a look at cost and the clinician’s relationship to the patient (short-term, long-term, etc.).

Timeline: CMS is supposed to post the operational list of patient relationship categories and codes by April 2017. The current plan is for clinicians to start using the codes on all Medicare claims beginning Jan. 1, 2018.

Dig In to the Patient Relationship Category Details

After an initial round of draft categories and comments, CMS posted new categories for consideration:

1. Continuous/broad: This is the category for clinicians responsible for comprehensive, principal care with no defined endpoint. The care may be direct or in a care coordination role.

  • CMS examples: Primary care provider or specialist also responsible for a patient’s comprehensive care

2. Continuous/focused: A specialist who works with a patient for a long time falls under this category.

  • CMS example: Rheumatologist treating only a patient’s rheumatoid arthritis

3. Episodic/broad: This category covers clinicians providing comprehensive care for a defined period.

  • CMS example: Hospitalist

4. Episodic/focused: A specialist providing time-limited treatment, like surgery or radiation, is in this category. The condition treated may be acute or chronic.

  • CMS example: Orthopedic surgeon performing a knee replacement and postop care

5. Only as ordered by another clinician: This is the category for those who provide care only when ordered by other providers.

  • CMS example: Radiologist interpreting image ordered by another clinician

Check Out Possible Role of HCPCS Modifiers

CMS also has to determine how to identify patient relationship categories on claims from physicians and practitioners, and this is where the potential new HCPCS modifiers come in. These modifiers are the leading contender because they offer several advantages:

  • There’s already a process in place for creating new HCPCS modifiers
  • CMS systems can accept HCPCS modifiers
  • A modifier appends directly to the service code, allowing for more precision in data collection.

How About You?

How have you been getting to know MACRA? Do you think there’s a better option than HCPCS modifiers to identify relationship categories?

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Translate HIMSS17 Tips Into Career Advice for 2017

Fri, Feb 24, 2017


health information technology

This past week, two of our newsletter editors from The Coding Institute attended health IT conference HIMSS17 and Tweeted highlights from sessions. One point that came through loud and clear is that no matter what job you have in healthcare, data connections are so intertwined you have to expand your thinking beyond your own department.

Here are a few pointers from the conference that you can apply in your day-to-day work and as you think about advancing your career. To see Tweets from the conference, check out @supercodergirl on Twitter.

1. Do Your Part — The Human Element Matters

The reliability of any tech depends on the input of people.

For instance, human understanding may affect data being entered, such as assumptions about whether hysterectomy means all or part of the uterus, advised SNOMED International’s David Markwell.

People make the decisions about what tech to buy and how to use it, too. That was my thought about the comment by Kurt Long from FairWarning that functionality often wins over security.

If you find yourself getting distracted while you work or fatigued during a decision process, stop and regroup so a momentary lapse doesn’t result in a mistake.

2. Make Your Voice Heard

While discussing Bundled Payment Care Improvement (BPCI), a component of the value-based payment programs, Lahey Clinic’s Cathy Ball stated that in her experience the people at CMS want to hear your thoughts.

The lesson here is that if you’re frustrated by a health IT compliance proposal or a workflow hang-up caused by a particular tech product, sending your constructive criticism directly to the agency or company involved will likely be appreciated and may lead to change.

(That goes for us here at SuperCoder, too. We love to get feedback about enhancements or additions you’d like to see to help you do your job.)

3. But Not Too Heard

Social media can be a great way to reach and communicate with patients and companies, but, in a session on managing social media risk, Kevin Campbell, MD, offered some food for thought.

First, Campbell mentioned the issue of identity. It boils down to this: Does an employee’s personal post reflect back on the employer? There are all sorts of legal and social complexities surrounding that, but it’s an issue to keep in mind.

Second is some good old common sense: If it’s not something you want your mother to see, then you probably shouldn’t post it.

4. Watch for Trends Affecting You

Changes in the technology available to treat patients trickle down to the business side of healthcare, too.

For instance, in a presentation on new care models, Amy Mechley, MD, discussed the growing field of telehealth services.

CPT® 2017  included many changes to telehealth coding that you should consider reviewing to educate yourself.

5. Train for Good Documentation Habits

Having documentation that supports code choice is important. But having that documentation in the right place is crucial, too.

For instance, with an EHR, a doctor may put exam documentation in the notes field. But to really take advantage of what health IT can do, that documentation may need to be in a discrete field for easier capture.

Make sure EHR training for your practice is thorough and offers support during the learning phase so that good habits get in place from the start (preventing future frustrations).

6. Don’t Change for the Sake of Change

One of my favorite comments came from Ascom CEO Holger Cordes: Pagers are still around, and, for some specific purposes, they’re not a bad answer.

This comment made me think that while there have been a lot of technological advances that really can make our jobs easier and our data more secure, upgrading without putting in some thought isn’t the best approach. If something new and pretty won’t work as well as something you already have, stick with what works. Lower costs and less regret!

7. Pair Up With IT

Bust out your research skills to get to know tech lingo, and work with IT staff to ensure your team has proper training. Everyone may not need an in-depth understanding of crypto-agility, but social engineering and shadow IT in the cloud are concepts each team member should know and know how to handle.

And this isn’t a one-time thing. New channels, even in social media, can bring new risks requiring training updates.

8. Stay Focused on Patient Care

With all the technical aspects to learn and compliance requirements to meet, we all risk getting bogged down in the details of health IT and forgetting that the end goal is better patient care.

ONC’s Lisa-Nicole Sarnowski made the argument that it really does benefit everyone to have access to the right info at the right time.

Consider the story told by an audience member about a lung cancer patient who had to physically carry her health information and images from specialist to specialist because there was no system in place for the doctors to share that information.

When you’re making decisions about what tech to buy or even just need a little motivation to make it through your next task, keep those patients in your mind.

How About You?

How do you view health IT? Do you make an effort to keep your tech skills up-to-date to help with your career goals?

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Pinpoint Your CAD Code Fast Using This Convenient ICD-10 Table

Tue, Feb 21, 2017


There are more than 3 million cases of coronary artery disease (CAD) in the U.S. each year, and that means you’re likely to see a lot of patients with this diagnosis at your practice.

Under ICD-10, you have to sort through a long list of combination codes for CAD with angina pectoris before you make your final code choice. Find the correct code faster using this simple table that helps you connect the patient’s CAD diagnosis to the angina pectoris status identified in your documentation.

Pinpoint Your CAD Code Fast  Using This Convenient ICD-10 Table

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Injection Laryngoplasty: Code Correctly, Collect $1,046

Mon, Feb 20, 2017

1 Comment

vocal cords

Hi, otolaryngology coders! Have you been enjoying the new code CPT® 2017 gave you for injection laryngoplasty? Today, let’s take a closer look at 31574 (Laryngoscopy, flexible; with injection[s] for augmentation [e.g., percutaneous, transoral], unilateral).

When Will You Use 31574?

Injection laryngoplasty is on the rise among ENTs. The procedure involves injecting an augmenting material into the larynx. The effect is to move the patient’s vocal cords toward the center to improve symptoms in patients with vocal cord paralysis and stenosis. For instance, Aetna “considers injections of bulking agents medically necessary for members with unilateral vocal cord paralysis” and includes these ICD-10 options as covered codes when you meet policy requirements:

  • J38.00-J38.02, Paralysis of vocal cords and larynx
  • J38.3, Other diseases of vocal cords.

Anything to Know From the MPFS?

Any time you’re reporting a new code, you should check out what the Medicare Physician Fee Schedule (MPFS) has to say.

Fees and RVUs: The MPFS assigns 31574 4.30 total facility RVUs, which calculates to a national rate of $154.32 for a physician performing the service in a facility.

The nonfacility rate is more impressive because it takes into account the added expense to your practice when you perform the service in your own office. The 29.16 total nonfacility RVUs add up to a national rate of $1,046.51.

Global days: The global period for 31574 is 000. Here’s the technical definition (be sure to heed the bold section at the end about generally not reporting a same-day E/M): “Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.”

Multiple procedures: Multiple endoscopy rules apply to 31574. The endoscopic base code for 31574 is 31575 (Laryngoscopy, flexible; diagnostic). If you think it’s odd that 31574 has numerically later code 31575 as the base code, keep in mind that 31574 is out of sequence in CPT®. You’ll find 31574 located out of order, just before 31579 (Laryngoscopy, flexible or rigid telescopic, with stroboscopy).

Bilateral bonus: Be sure to catch that the 31574 descriptor specifies unilateral. The MPFS gives the code a bilateral indicator of 1, which means, “150% payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers, or with a 2 in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150% of the fee schedule amount for a single code. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules.”

Remember: The M in MPFS is for Medicare, so you can’t assume these rules apply to private payers. If you have similar fee schedule information from your other payers, be sure to check for any variations you need to know before reporting to them.

How About You?

Have you been using 31574? Are there any other procedure you’d like to see get dedicated codes?

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